Angela Lambing, MSN, ANPC, GNPC, is a Clinical Support Specialist with Bayer HealthCare. This post is based on her session “Hemophilia: What You Need to Know” taking place at the 2016 National Conference on Correctional Health Care in Las Vegas, October 22-26, 2016. Learn more about the conference and register HERE.

Jena, an RN working in a medium security state prison, is making sick call rounds. In housing unit C she is approached by an inmate in his late 30’s. He is barely able to hobble into the sick call room. He says he has hemophilia and is experiencing a bleed in his right ankle after having to walk with shackles for several hours earlier in the day. He also said he told those at intake two weeks ago that he had the condition and needed an infusion three times a week but no one has set him up with anything yet.

The 411 on Hemophilia

Hemophilia is an X-linked recessive bleeding disorder. Mothers carry the gene and pass on to their sons. This results in a bleeding disorder described as Hemophilia A (FVIII deficiency) or Hemophilia B (FIX deficiency). Severe hemophilia (<1% Factor level where the normal range is 50-100%) causes acute bleeding episodes, bleeding after injury, and spontaneous joint bleeding that leads to end-stage joint disease. The mainstay of therapy is replacement of the missing factor to raise levels to a near normal. This reduces bleeding risk.

A Common Inmate Condition?

While over 20,000 men are estimated to have hemophilia in the US, it is unclear how many incarcerated men have the condition. Given that this is a male-dominated disease and more inmates are male, it is expected that correctional nurses, like Jena, may encounter patients with the condition.

Hemophilia Issues Behind Bars

If you have a patient with hemophilia, they are likely to know more about the condition than you do. Take their lead about treatment and injury. This is a life-threatening condition that can need immediate attention. Here are a few important areas to consider for hemophilia patients.

Bleeding may not be objectively evident: Listening to the patient who states he is having a bleed, even though it might not be readily evident. If you wait until you see swelling, warmth, or pain, it may be too late. By then, blood is already in the joint, causing damage.

Treatment coordination: Develop a relationship with the patient’s primary provider who manages their hemophilia. As an expert in management of this disease, they are an excellent resource and liaison for treatment.

Security coordination: Hemophilia is an example of a medical condition that our officer colleagues need to know about. They need to be aware of the high potential for bleeding events from head injury or fights. Work details may need modified as repetitive motion can lead to joint bleeding.

Patient self-care: Treatment for this condition requires the replacement of the missing factor. This is given in an infusion by IV push. Patients are trained at an early age to start their own IVs, prepare the medication and give it to themselves IV push. Your patient may know the best veins to use or know their way around the equipment. On the other hand, our patient population is known to make poor health decisions. Some hemophilia patients may not be managing their condition well and, therefore, have severe joint disease from frequent bleeds.

High cost of treatment: Factor infusions are expensive. Work with the patient’s regular hemophilia infusion center to develop a cost-effective option for the 3-times-per-week infusions many with hemophilia require.

Jena had to fast track a solution for this inmate. She called for assistance and had him transported by stretcher to the prison infirmary. The prison medical director contacted the patient’s primary provider and arranged for an emergency transfer to the local hospital. The patient received factor infusions and was monitored for other bleeding such as intracranial bleeding. By the time he had returned to the prison, arrangements had been made for regular infusions and the Health Services Administrator had scheduled staff inservices on the condition.

National Resources

By the way, federally-funded hemophilia treatment centers are located in each state within the US. These centers are experts in management of the disease. General hematology/oncology practitioners may not be experts or have the latest and greatest information related to this condition. You can find the nearest hemophilia treatment center (HTC) by visiting this site and typing in your city or state.

Do you have patients with hemophilia? Share your experience in the comments section of this post.

“You know my name, not my story. You’ve heard what I’ve done, but not what I’ve been through.”

― Jonathan Anthony Burkett

Prisoners have got to be the most misunderstood people-group in the country. Yes, many of them have done terrible, even evil, things; leaving a trail of hurting victims and families. Yet, a large portion of our patients are incarcerated due, in part, to the family they were born into, the environment they grew up in, and the poor decisions they made along the way. This is not to say that justice is not served by doing time for criminal activities. This is, instead, to say that, as nurses, we need to have some understanding of our patient’s stories and what they have been through in order to be effective in our practice in the criminal justice system. Indeed, we also need to know the harsh reality of their living conditions behind bars.

A Bleak Background

Incarcerated patients are more likely to come from disadvantaged backgrounds with less education and employable skills. They have high rates of learning disabilities that affect understanding of prison rules and health information.

Those from low socioeconomic backgrounds are likely to have grown up and currently live in neighborhoods with high unemployment and high crime rates. Gangs can be prevalent with great pressure to participate in gang activity.

They are more likely to have been abused in the past by parents or spouses. This means higher rates of traumatic brain injury and post-traumatic stress disorder.

Our patients are less likely to have regular health care and more likely to be drug, alcohol, and tobacco involved. The consequences of years of health neglect and abuse result in most inmates having a biological age older than their chronological ages. In fact, many experts consider the incarcerated patient to be 10 years older than their chronologic age when it comes to the ravages of age and illness.

Poor living conditions and lack of attention to or understanding of personal health habits leads to higher rates of infection. More infectious disease, especially HIV, Hepatitis C, sexually transmitted disease, and tuberculosis are found in this patient population.

Many have undiagnosed or untreated mental illness such as depression, mania, and psychotic disorders. Mental illness can contribute to criminality. Borderline personality disorders that lead to poor impulse control, self-injury, and aggression are often present.

What this means for nursing care: Our patients come into the criminal justice system in great need of health care. The symptoms of their health conditions may not emerge until drugs and alcohol are cleared from their system. Mental illness is exacerbated by security practices such as control and isolation. Our patients may not understand what we generally consider simple health information. The stress of incarceration may overload mental circuits and lead to aggressive or self-harming activities.

Harsh Living Conditions

The criminal justice system was built on a foundation of punishment for crimes against individuals and society. While rehabilitation is also a criminal justice concept, it falls far behind punishment as a part of most correctional cultures. Power and control are evident in many of the facilities in which nurses work. Although there is great variability among systems, here are some common ways a punishment culture works out in the lives of our patients.

Prisoners are stripped of most of their personal property and much of their identity; often becoming an ID number.

Individuality is suppressed. Special privileges are discouraged.

Time is controlled. Prisoners cannot decide when they will eat, sleep, exercise, or shower.

Housing units are stark and institutional. Cells are small and uncomfortable. Beds have thin or non-existent mattresses. Toilets may have no seat. Air quality may be poor with foul odors.

Many older facilities lack adequate heating in winter and cooling in summer.

Prisoners are stripped of privacy, even when showering and using the toilet. Officers may be of either gender.

What this means for nursing care: With nursing care focused on the good of the patient, nurses provide a rare opportunity for a caring interaction for prisoners. This can be turned into an opportunity to obtain as much comfort as possible. Many incarcerated patients will seek out medically-acquired perks that set them out as different or special. Correctional nurses need to be alert to this motivation and objectively determine need based on health and well-being.

Trusting and Being Trusted

A trusting prisoner does not last long in the correctional system. High rates of antisocial behavior among the incarcerated means there are predators always seeking out victims among other prisoners and among the staff. Likewise, this prevailing inmate personality leads to a lack of trust toward any prisoner. Thus, health concerns such as chest pain or seizure activity can be disregarded as ‘faking’ by both officer and health care staff.

What this means for nursing care: Lack of trust is bad for any relationship. The nurse-patient relationship is hindered when patients don’t trust that a nurse will focus on their best interest rather than the interests of the correctional system. Likewise, nurses can easily become cynical and disbelieving if they don’t trust that a patient is being honest when reporting symptoms or past history. Correctional nurses must work to gain the trust of their patient population while seeking to be objective in evaluating patient symptoms and complaints. An awareness of manipulation tactics and methods for avoiding manipulation is also important.

Respecting and Being Respected

The power structure in a correctional institution can easily lead to a culture of disrespect. Once this attitude takes root, it can spread and escalate. Disrespect most often is directed at the prisoner population but deep seated disrespect in a facility shows itself in staff and management interactions, as well.

What this means for nursing care: Basic human respect is foundational to ethical nursing practice. Correctional nurses must strive to be respectful in all relationships; with the patient, fellow health care staff, and officers. Disrespect is shown through voice tone, body language, and actions. It can be a struggle to provide nursing care without judgment of a patient’s lifestyle choices, gender expression, or value system. However, we can disagree with their choices without being disagreeable. Where these factors are self-destructive or risky, we have an obligation to offer opportunities to modify that behavior toward improved health.

What do you think? Does understanding the world of your patient help you provide correctional nursing care? Share your thoughts in the comments section of this post.

USA Today is reporting that nurses, physical therapists and other senior medical staffers in the Federal Bureau of Prisons are being routinely assigned officer duties and other security-related shifts to fill chronic personnel gaps. The news item discusses this action in light of the decrease in already diminished health care in the FBOP and that is certainly an issue with the practice. Another concern, though, is an ethical one. Is it ethically healthy for a nurse to one day be in a nurse-patient relationship with an inmate and on another day be in a security-focused relationship? Is that not confusing to both the nurse and the patient and does that adversely affect patient care? Panelists discuss their perspective on being both an officer and a nurse.

The Tennessean has a two part series published about Hepatitis C status reporting to victims of rape. Right now the Tennessee state system does not alert rape victims to the HCV status of the rapist. The piece goes on to outline the epidemic of hepatitis C in the criminal justice system and the need for more treatment. We have talked about the expense of Hepatitis C treatment and the tricky nature of starting treatment while incarcerated. As we see this condition unfold in both correctional and public health, does it look like Hepatitis C is the new HIV – A blood borne transmitted disease with deadly consequences and disproportionately high rates in our patient population that requires a consistent and currently expensive treatment program? Panelists discuss the similarities.

The Detroit Free Press reported on a settlement reached between a former female inmate and the Michigan State Prison System. The plaintiff had multiple health problems and lost both of her legs in prison because of health issues. When her second amputation developed MRSA, she was placed in a segregation cell with no means to get to the toilet or contact officers for assistance. We are seeing more stories about the treatment of disabled inmates in the criminal justice system. It doesn’t appear that medical staff were named in this suit. From what we know about standard health care practices in segregation settings, were there opportunities for nurses to advocate for disabled inmate conditions?

On a brighter note, things are looking up for mental health inmates in the Pennsylvania Prison System. Our last story is the announcement that 1,000 PA prison staff members have received Crisis Intervention Team (CIT) training aimed at improving response to inmates with mental health needs. The training program is part of a system-wide initiative to place an inmate’s mental health at the forefront of treatment in prison. Crisis Intervention Team training includes increasing understanding of the ways mental illness may affect the inmates as well as providing skills to de-escalate crisis situations. Panelists discuss their own experiences with CIT in correctional settings.

Share your thoughts on these items in the comments section of this post.

Rich Feffer, MS, CCHP, is Correctional Health Programs Manager for the Hepatitis Education Project in Seattle, WA. This post is based on his session “Providing Hepatitis Education to Inmates” taking place at the 2016 Spring Conference on Correctional Health Care in Nashville, TN, April 9-12, 2016. Learn more about the conference and register HERE.

Hepatitis A, B, and C are viral infections that cause inflammation of the liver and they are disproportionately common condition among the inmate patient population. Hepatitis C (HCV), for example, is found in 10-40% in the corrections population compared to only 1-2% in the general population. There is still a great deal of misinformation and stigma about viral hepatitis. Our patients, whether currently battling the disease or not, need to understand disease transmission and prevention. Those currently living with viral hepatitis also need to understand treatment options, self-care, how to navigate the correctional health care system and linkage-to-care options upon release. One model of a successful hepatitis education program is found in the state prison system of Washington.

Hepatitis Education at the Washington State Prison System

Since 2001 the Hepatitis Education Project (HEP) has provided inmate health education regarding hepatitis and other blood-borne pathogens at all 12 Washington State prison facilities. HEP is a community based non-profit organization that provides advocacy, education, and direct services for viral hepatitis.

The main education program is a two-hour hepatitis and blood-borne pathogen class delivered by HEP to inmates in all 12 WA prisons and one work release facility. The class is taught monthly at the men’s intake facility, every-other-month at the women’s intake facility, and at least twice annually at all other facilities. A total of 64 classes are held across all 13 facilities, reaching about 900 inmates annually. Class participation varies, but is typically voluntary unless the local facility or program requires it. There is a signup process and classes are advertised in living units and other high traffic areas. Recently, remote classes were added using a Webinar process.

A second program was added in 2015 and consists of six 2-hour sessions in which inmates are trained as peer educators for HIV and viral hepatitis risk reduction. The program, called Project SHIELD, is an evidence-based intervention adapted from CDC materials for use in corrections. SHIELD “Peer Educators” are taught risk reduction skills and communication strategies for talking to people in their social networks about risk reduction. The program started with a pilot at two facilities. So far, 79 inmate peer educators have been trained after a thorough screening.

Outcomes of a Hepatitis Education Program

Qualitative feedback shows that class participants both enjoy and appreciate the opportunity to learn about these topics. Inmates have shown hepatitis and HIV knowledge increases on pre- and post-tests. Medical staff also report an increase in requests for vaccination and testing after classes take place and have reported learning new information themselves from classes they observe, especially pertaining to community-based resources.

As a side benefit, the presence of HEP educators in the facility increases awareness of available resources. For example, HEP staff routinely supply health care staff with educational handouts and literature about community-based programs to help patients on release.

The effect of the SHIELD program is still being evaluated, but inmates report increased knowledge and understanding of disease transmission along with increased confidence in their own communication skills and an intention to reduce their own risk in the future.

Tips for Starting a Hepatitis Education Program

Starting and maintaining a Hepatitis Education Program takes time, collaboration, patience and persistence. Here are a few tips to help make it work.

Evidence-based Models: Use evidence-based models and be ready to explain why they are important and why they are beneficial for the system to implement both in the short and long term.

Keep Records: Once implemented, keep records and data to show the impact of your program. This will sustain the support and resources needed to continue the program.

Communicate with Stakeholders: During the entire process it is important to communicate effectively with all relevant stakeholders. Coordinating programs in corrections involves many departments within a correctional system such as administrative staff, custody, program staff, and medical. Make sure all parties are at the table during the planning process to minimize problems down the road. When challenges do occur, be professional, respectful, and responsive.

Find a Champion: Identifying a champion in your system or jurisdiction can help in systems where implementing change or new systems may be difficult. The HEP program benefitted greatly from the presence of a knowledgeable champion inside the WA Department of Corrections.

An effective inmate hepatitis education program can help control the spread of hepatitis while assisting patients to manage their condition successfully.

How do you provide hepatitis education in your setting? Share your tips in the comments section of this post.

The Bureau of Justice has published a special report on disabilities among prison and jail inmates. Using data from the 2011-2012 National Inmate Survey, this report quantifies self-reported prevalence of disabilities such as hearing, vision, ambulatory, cognitive, self-care and independent living limitations among the incarcerated. This may be the first time disability has been reported by the BJS, they list no prior reports on their website.

It is an eye-opening report with significant implications for nursing practice. Our patient population has significantly more disability than the general population in almost all areas of disability. Over 30% report some type of disability with cognitive being the most prevalent.

In our second story, a nurse at Washington State Prison – which is in the Georgia Prison System, not in the state of Washington – reported what she considered negligent treatment by the prison medical director and the shredding of some of her nursing documentation that would have corroborated her concerns. She alleges she was then locked out of the prison and lost her position in retaliation. I talk to correctional nurses across the country and losing their job for reporting patient concerns is a real stress and moral dilemma.

Our next story is about a provision in the Ohio state budget to empower the Ohio Prisons Director to move nonviolent, low-level felony drug offenders into community programs and electronic monitoring rather than prison when they have less than a year to serve. Although this can affect up to 2100 current inmates, the first priority will be women who tend to have short sentences for nonviolent drug crimes and struggling with mental-health and addiction issues.

Our last story is good news for women in the criminal justice system who are pregnant. Six national organizations are calling for federal policymakers to support and encourage state and local government efforts to restrict the use of restraints on incarcerated women and girls during pregnancy, labor, and postpartum recovery. The American Psychological Association seems to be leading the coalition of organizations that includes the American Congress of Obstetricians and Gynecologists, the American Jail Association, The Human Rights Project for Girls, The National Commission on Correctional Health Care, and the National Council of Juvenile and Family Court Judges. They cite the 2012 Best Practices in the Use of Restraints with Pregnant Women and Girls Under Correctional Custody published by the Bureau of Justice Assistance in the statement.

What is your take on these news stories? Share your thoughts in the comments section of this post.

In most settings where nurses practice, the interdisciplinary team includes other health care professionals such as physicians, diagnostic technicians, and pharmacists. Sure, there may be unlicensed ancillary staff in the mix such as admissions clerks and supply personnel, but everyone is generally focused on the goal of providing health care. Not so in a correctional facility. Here, in addition to other health care professionals, correctional nurses must also collaborate and negotiate with correctional officers as legitimate members for the health care team. It is a mistake to minimize the impact of good communication among nurses and officers on safe patient outcomes. Armed with an understanding of the correctional officer role and responsibilities, correctional nurses can successfully advance inmate healthcare in a correctional setting.

Officers are Professionals, Too

If you are a team sport enthusiast, you know that everyone on the sports team has a position to play and each player needs to play their position as well as understand the role of other team players. It is no different for the correctional health care team. Everyone has a role to play and it is important to both understand and acknowledge the different perspectives between security and health care. Correctional officers are professionals in their field and their perspective is important to many of the health care decisions needed for the patient population.

There are likely to be philosophical differences between the two disciplined, though, and it is important for correctional nurses to develop a keen understanding of the security perspective in order to successfully advocate for a patient’s health needs. Most of these differences come from different orientations; officers are taught that security and rule compliance is paramount, while nurses are taught that caring and compassion is paramount. The truth is – both are right. Some call this the custody-caring friction between the security and nursing perspectives. It may be a difficult adjustment to learn to work with officers without sacrificing a nursing perspective on the patient population. For example, officers may be critical of nursing concepts like compassion and patient advocacy. Their ethical framework is less bound by the nursing concepts of caring, advocacy, and human dignity. However, honesty, justice, and civil rights are all part of most professional codes, so there is strong overlap between the professions.

Correctional officers are professionals, too, and deserve respectful treatment. Nurses who are arrogant or act superior to their correctional colleagues don’t last in the specialty. We may come from different worldviews and we may have differing opinions, but both professions have a vital role in the facility. The happiest correctional nurses are those who build collegial relationships with the officers with whom they work.

Aretha was Right – R-E-S-P-E-C-T

Civil and respectful communication and behavior among the disciplines is the secret to collaboration success. This means respecting the role officers play in successful health care outcomes. Nurses can role model respectfulness even if custody officers are less than civil in return. This, of course, is difficult, but can also be empowering and powerful. In a culture of disrespect, respectful behavior stands out.

It is important to acknowledge and respect the security perspective without internalizing or modeling it. Correctional nurses are not custody officers and should not try to be so. As stated earlier, each team member has a role to play and should not try to play the position of other team members. Unfortunately, some nurses slide into a custody mindset without realizing it. It is helpful to regularly and mindfully recenter your mind to your role as healer. It may be helpful to establish a ritual where this mindfulness takes place as you daily enter the security checkpoint.

Security personnel are like most people – they have preconceived notions about how nurses behave and think. Sometimes, correctional staff can be critical of nursing concepts like compassion and patient advocacy, but they still do not like it when nurses do not act as expected. Role modeling expected nurse behavior may invite some teasing, but generally the security staff will have greater respect for the nurses who remain true to their professional values.

When Asked to Do Something that is Out-of-Bounds

Officers don’t always know what nurses do and may have misconceptions about what can be asked of a nurse. If unprepared for these requests or unknowledgeable about licensure boundaries, correctional nurses can be end up practicing outside practice boundaries in an attempt to be helpful.

Have a well-thought-out response for when you are asked by an officer or security administrator to perform a function that is outside your professional or ethical boundaries. Remember, these folks may not know they are asking you to do something unlawful or unethical. Give them the benefit of the doubt. Here is an example to get you started thinking about how you can respond respectfully and collegially. “I’d really like to help you out with this issue but what you are asking me to do is beyond what my nursing license allows (or is not considered ethical for a nurse to do). Let’s see if we can come up with a solution that works for all of us.” Having a prepared response will ease the stress of declining a request and start the discussion toward a solution.

HIPAA and Officer Need-to-Know

Although it is important to consider correctional officers as part of the health care team, their legal access to patient health information is limited. Officers, however, do require information about an inmate’s health status when it is needed for the inmate’s health or for the health and safety of staff and the inmate population. Many times you need to enlist the help of a correctional officer. They can be your eyes and ears in the housing unit if you ask them.

That means officers may need to know about medical conditions or disabilities that require special equipment or scheduled appointments. Some medication side effects require additional attention or changes in the inmate’s work duty. Joint surgery may limit movements or abilities that security needs to be aware of. Fortunately the Health Insurance Portability and Accountability Act (HIPAA) regulations take into account the need for some information sharing within the correctional setting and have spelled this out is the 45 C.F.R. 164.512 (k) (5) (i) section of the code.

Officers need to be alert to an urgent need of medical attention such as an unstable diabetic, seizure disorder, or post-concussion mental status

The condition needs special housing or activity interventions such as pregnancy, back injury, or joint replacement

The patient is allergic to a common element in the environment or diet such as peanut butter or bee sting

If in doubt about the need or the advisability of communicating particular health information, seek guidance from the health supervisor or medical director. Be sure the information shared can be supported by one of the six necessity requirements listed above.

With a focus on maintaining professional nursing integrity while also understanding the correctional officer perspective, most nurses can successfully negotiate the caring-custody divide and establish a collegial and respectful relationship with officers at their facility.

Have you been in a difficult negotiation situation with officers at your facility? Share your story and tips in the comments section of this post.

Laura Mish, RN, works in a medium security prison with an average daily population of 3300 male inmates. Here is her correctional nursing tale.

The Background

Having been a correctional nurse at a state prison for nearly 16 years, I have many stories to tell. Some are sad, some are funny, and then there are those that you will never forget. They change your perspective, not only on correctional nursing, but on nursing in general. I have learned invaluable lessons from many of my inmate patients, and I would like to share one with you.

The Tale

Several years ago, while working one of the medical units in general population, I received a call from one of the officers on a housing unit. It was just past 2pm, which is change of shift for medical as well as security staff. The officer told me that he had an inmate that was complaining of a headache. He said the headache was his only complaint, but that it was getting worse as the day went on. Thinking that this was going to be a fairly easy emergency sick call, I told the officer to send him down.

While I was waiting for him to arrive, I reviewed his medical record and noted that he was rarely in medical for any issues, and had no current medical diagnoses listed. The inmate arrived in medical about 10 minutes later in no visible acute distress other than the look of discomfort I could see on his face. I took his vital signs, which were all within normal range, checked his eyes and pupils, and did a general assessment on him including lung and bowel sounds. At that point, I could find nothing abnormal. While doing my assessment, I was asking him questions about his symptoms to try and rule out any medical condition other than a general headache. The only other symptom he said he was experiencing was blurry vision, which can occur with headaches, especially migraines. I checked his visual acuity with the eye chart but found no major deficit. He said he did not normally wear glasses, so I assumed that the headache was not related to him having blurry vision from being without proper eyewear.

But something was telling me that there was more going on with this man than a simple headache. After probing further into any other symptoms, and finding none, I asked if I could take a fingerstick blood sugar reading; explaining what it was for. The result was shocking. The glucometer didn’t have a reading that high! I explained to him what this reading meant, and asked him if he had ever had his blood sugar checked previously, or was told that he was diabetic, and he stated he had not. When asked if diabetes ran in his family, and he confirmed that both of his parents were diabetic. Armed with the glucose reading and family history, I asked about unquenchable thirst, hunger, frequent urination, and other indicators of hyperglycemia. When he responded affirmatively to all these questions, I lightheartedly responded that “I thought you told me that you weren’t having any other symptoms?” This brought a chuckle and helped ease the anxiety I could see that he was feeling. At that point, I explained to him that all of the symptoms he stated he was experiencing were signs of diabetes, and explained why he had those particular symptoms. He acknowledged understanding everything I was explaining to him.

Luckily the nurse practitioner had not left for the day, so I was able to have him seen immediately. Once evaluated by the NP, treatment orders were written and I administered insulin for the hyperglycemia and ibuprofen for the headache. I also scheduled him for ongoing insulin and blood glucose monitoring. Finally, we started diabetes education with literature and dietary information. Before he left the medical unit, I rechecked his blood sugar to be sure it was in a better range.

Before sending this patient back to his cell, I acknowledged his anxiety and confirmed that we would help him manage this new condition. He seemed much more relaxed after I took the extra time to assure him that he was not going to have to go through this alone.

The Lesson

This story is a reminder to take those few extra minutes to dig deeper when your instinct is telling you that something is wrong. Had I not done this, it’s possible that he may have gone into ketoacidosis during the night and no one would have known until it was too late. Since this experience I am more inclined to check someone’s blood sugar than I would have before.

Also, I learned that understanding the patient is so important. For example, this inmate did not normally complain or come to medical frequently with various issues. Yet, this issue was important enough to him to seek out attention. This added to my suspicion that something was not right and to dig further.

Do you have a tale to share with others? Send your story to lorry@correctionalnurse.net. Let’s help each other become better correctional nurses!

A well-informed patient can be a great assistance in reducing medication error. The more patients understand about the medications they are taking, the better they can assist with monitoring treatment practices and questioning when unfamiliar medication is offered. Here are four ways to engage your correctional patient in the medication process to avoid error.

Be Sure Your Patients Know the Important Stuff

Patients are best able to contribute to medication safety by having both general and specific knowledge of their medication program. Low general health literacy contributes to misunderstanding and gaps in patient medication. The level of understanding of the medical process, and specifically the medications ordered for treatment, affects medication adherence, whether provided by direct observation or through a self-administration process.

Medication allergy. General knowledge includes an understanding of any medication allergies a patient has and the symptoms they see when taking these medications. Indeed, understanding the difference between side effects and allergies are of particular importance for proper treatment. For example, a patient may state that they are allergic to aspirin when what they have experienced is stomach burning when they have taken aspirin on an empty stomach. Therefore, it is important to obtain descriptive information about medication allergies when documenting a health history.

Medication effect and side effect. Even when patients come into the criminal justice system on long-term chronic medications they may have misconceptions about why they are taking the medication, the expected effects of the medication on their condition, and what side effects they should be monitoring. There is even greater need for this information if new medications are added to the regimen.

Self-administration practices. Self-administration practices such as dosing and timing of medication self-administration can be an added challenge for patients, especially those with low literacy skills. It may take more than mere labeling instructions to be sure patients are appropriately self-administering medications allowed in the keep-on-person program. Besides basic information about medication effect, side effect, dosing, and timing, patients should be able to identify an interactions with food or other medications as well as any precautions that need to be taken such as avoiding direct sunlight or not stopping the medication abruptly. Because incarceration can restrict movement and meals, health care staff should also be sure self-administration practices are adapted to the particular situation of the patient.

Give Them a Way to Communicate Directly with You

A knowledgeable patient is particularly important in a correctional setting where security barriers can cause medication delay or omission. A direct communication process between the patient and the health care staff assist in allowing patients to speak up when they have concerns about medication administration schedules. Many inmates use the sick call slip process for communication with health care staff, although other systems may need to be initiated if this is burdensome to the sick call process. For example, some settings have electronic communication through a kiosk system and others have a phone message system for inmate/health care communication.

Help Them Understand Their Role

Incarcerated patients may need to be directly told to speak up about their medical condition and to question medication administration that does not fit with their understanding of their medical treatment. The power-over structures within a correctional setting does not encourage proactivity or self-efficacy in the patient population. Health care staff need to encourage and support patient participation in the care plan, including actively addressing unfamiliar medication administration. Staff administering medications must be willing to explain any changes in the regimen. Here are a few common times when medications may be unfamiliar to a patient.

New patients may have medications switched from non-formulary brands to generic equivalents on intake into the facility.

Patients may not understand the information provided by a prescriber regarding a dosage change.

A new medication formulation including a change in size or color of the pill may be used while patient-specific medication is shipped from the pharmacy.

Create a Solid Medication Self-Administration System

Involving the patient in administering their own medications can improve patient safety and assist with developing independent health habits. As identified earlier, patient education on drug and food interactions is important; so is information about medication effects and side effects. Confirm that the patient understands what situations require medical attention and the process for obtaining more medication when the supply is dwindling. Here are some tips for a safe and effective keep-on-person (KOP) medication program.

Establish a system for distributing and reordering KOP medications. Be sure patients understand the system and their responsibilities. Many medical units ask that patients show up at a treatment or pill line to reorder medications when there are about 10 doses left. This allows time for order filling.

Incorporate KOP medication into the Medication Administration Record (MAR) process. All medications provided to the patient should be documented in a single place to assist in communication among care providers and decrease confusion in the treatment plan.

Be sure every medication card has the patient’s name and ID, as well as medication and prescription information. During cell sweeps, medications will be confiscated if not in the possession of the person whose name is on the card.

If providers give out medications during medical sick call, sometimes called ‘Provider Packs’, the medication cards should have the inmate’s name and ID written on them by the provider along with date and signature.

In like fashion, over-the-counter medication distributed by nurses during sick call should be labeled for the individual inmate with date and nurse signature.

Security staff should be able to confirm the rightful owner of any medication found in the general prison population.

A regular spot-check process for patient compliance with KOP medications is helpful. Randomly check KOP cards in mid-cycle to determine proper use. For example, twice a week, a number of inmates with KOP medications could be called to report to the medical unit with all KOP cards. Nurses can use this time to validate proper use and reinforce patient teaching.

How do you involve your patients in monitoring their medications? Share your tips in the comments section of this post.

Correctional nurses face a daily struggle to care for their patients while delivering much-needed healthcare in a restricted environment where they may also fear for their own personal safety. How can nurses truly care for and care about their inmate patient population? This is a question many of us in the specialty grapple with as we try to elevate the professional status of correctional nursing. Caring has been described as the essence of professional nursing practice, therefore we must establish the characteristics of this concept as it is enacted in the criminal justice system.

Weiskopf studied nurses’ experience of caring for inmate patients and discovered a number of limitations in our setting . Nurses in this study described the need to negotiate boundaries between the culture of caring and the culture of custody to establish relationship with custody staff in order to be effective. One surprising finding of the study was the extent to which the negative attitudes and behaviors of other nursing staff affected nurses who were attempting to provide compassionate nursing care.

Many nurses working behind bars feel an obligation to care and often struggle to find ways to do this in a hostile environment. Yet, developing a structure and process for caring may be the core defining characteristic of our specialty. Here are some suggested ways nurses enact caring behaviors in corrections:

Educating patients about their health conditions and self-care principles

Maintaining a nurse-patient relationship that is within the helpful zone of professional boundaries

Advocating for the health care needs of a patient when necessary

Showing compassion and respect

Presenting a non-judgmental manner

Listening to what the patient is saying

Helping patients through a difficult situation

Correctional nurses are confronted daily with a struggle against a tidal wave of organizational culture convinced that we should not be caring ‘too much’ for our patients. Caring for murderers, rapists, and criminals takes true grit and a more serious definition than a superficial application of a warm positive emotional response or empathetic word. We are the ‘Tough Love’ folks on the nursing caring continuum.

Consider these unusual ways that a correctional nurses cares for patients:

Not accepting a gift from a patient

Letting a patient know that you know the rules and they should not ask you to violate them

Asking the patient to complete a sick call request for their rash that they want treated during pill line

Being diligent with mouth checks during pill line

All of the examples above constitute an action or activity that is helpful for the patient; whether it avoids penalties, provides boundaries, or prevents self-harm. Caring seeks the best for the other in any situation.

Have you found it difficult to care for patients in the criminal justice system? Share your thoughts in the comments section of this post.

Recently I reviewed the medication administration practices at a small city jail. The nurse had been there many years and was able to complete the delivery of medication on 3 floors of inmate cells very quickly. In the unit common area she called out the names of the inmates. Inmates would present themselves and a soufflé cup of pills was poured into their open hand. This was happening so quickly that I could not always see whether the inmate was tossing the medication into his mouth or his pocket. Neither nurse nor officer did an oral check. No inmate had a wrist band or other identification.

Can you name all the safety issues of concern in the described process? I hope that patient identification was high on your list of concerns along with medication diversion and hoarding risk…..but I’ll leave those last two for another discussion. “Wrong Patient” medication and treatment errors are frequent in health care delivery. They are a top concern for The Joint Commission (TJC) and are high on their list of National Patient Safety Goals again this year.

Times of particular concern for “Wrong Patient” errors are during medication administration, blood draws, blood transfusions, and surgical procedures. For the correctional setting, medication administration and blood draws would be most common.

Improve patient safety by applying these TJC recommendations:

Two methods of identification: Two forms of patient identification in corrections may include verbal name check (first and last) and inmate ID#. Photo ID cards or wristbands are ideal. Some computerized systems are able to access digital photos.

Involve the patient: Patients should know their meds and ordered lab tests. If there is a question about a medication or test, double-check the order. Patients can often help avoid an error.

Label in front of the patient: Label lab tubes in the presence of the patient. This can help avoid tube mix-up.

Include patient identification in orientation and training: Don’t leave patient identification processes to chance. Be sure all staff follow safety processes by learning them at orientation and through reinforcement during management rounds.

I shared my concerns with health care administration that day at the city jail described above and made recommendations for how they could improve their medication administration process to include 2 forms of patient identification.

What is your process for patient identification in medication administration at your facility? Share your procedure in the comments section of this post.